Impact of the COVID‐19 virus outbreak on 24‐h movement behaviours among children in Saudi Arabia: A cross‐sectional survey

Abstract Background In March 2020, the World Health Organization (WHO) declared the coronavirus (COVID‐19) outbreak as a pandemic. This led many governments to place restrictions on population movement to aid in pandemic control. These restrictions were expected to produce some type of impact on the daily lives of children and their families. The purpose of this study was to investigate the impact of COVID‐19 on 24‐h movement behaviours among Saudi children aged 6–12 years, during the pandemic. Methods An online survey of Saudi parents (n = 1021) was conducted between 1 October to 11 November 2020 to gather information about the impact of the COVID‐19 outbreak on children's 24‐h movement behaviours, parent and child factors that may be associated with movement behaviours, and perceived changes in children's movement behaviours. Results Only 3.4% of Saudi children met all components of 24‐h movement guidelines. Compared with before COVID‐19, children's PA levels declined, they slept more, and their use of electronic screen devices significantly increased. The perceived changes in PA and SB were more unfavourable among girls than boys. Children of older parents, mothers, and those with lower education levels and lower monthly incomes were more likely to meet 24‐h movement guidelines. Conclusion The COVID‐19 virus outbreak unfavourably affected Saudi children's movement behaviours, more specifically, girls, which should be taken into account in future research. The results provide an insight into what has changed because of the COVID‐19 restrictions and could be considered as part of the response strategies in Saudi Arabia.


| INTRODUCTION
In March 2020, the World Health Organization (WHO) declared the coronavirus (COVID-19) outbreak as a pandemic (WHO, 2020). Many governments placed restrictions on population movement to aid in pandemic control (Han et al., 2020). These restrictions likely impacted children's physical activity (PA), sedentary behaviour (SB), and sleep.
Children spent less time outdoors, which is associated with PA levels . School closures, which affected more than 1.5 billion children globally (Bates et al., 2020), also reduced opportunities for PA (Guan et al., 2020).

COVID-19 restrictions affected children's opportunities to meet
24-h movement guidelines (Guerrero et al., 2020). Studies have found that during COVID-19, most children did not meet PA or screen time (ST) guidelines, and there was an increase in ST, social media use and in sleep duration, compared with before COVID-19 (Al Hourani et al., 2021;Kovacs et al., 2021;Moore et al., 2020;Xiang et al., 2020).

More than 140 million children live in the 22 Arabic countries, including Saudi Arabia (Child Labour in Arab States & International
Programme on the Elimination of Child Labour (IPEC), n.d.). Across these countries, childhood obesity and sedentary behaviour levels are high and increasing (Farrag et al., 2017;Sharara et al., 2018). Further, there is a lack of evidence from these countries on the impact of COVID-19 on 24-h movement behaviours and on important health outcomes (obesity, executive function, motor development, and bone health) across the years of primary school. Assessing the impact of COVID-19 during the elementary school years is important to monitor prevalence and changes in adequate motor development (Simons et al., 2008;Valentini, 2012).
To our knowledge, no studies have examined the impact of COVID-19 on movement behaviours among school-aged children in an Arabian country. By January 2022, the number of COVID-19 cases has exceeded 575,293 in Saudi Arabia with more than 8892 deaths (Johns Hopkins University, 2021). These are the highest of any Arabian country and have prompted long-term government restrictions such as school closures and home quarantines. Schooling was conducted remotely for a long period of time (from March to November 2020), and this, along with the other restrictions imposed, likely resulted in changes in the time spent in movement behaviours. Given the high and increasing rates of child obesity in Saudi Arabia, these changes due to COVID-19 could have significant impact on children's health and development. Therefore, the purpose of this study was to investigate the impact of the COVID-19 outbreak on 24-h movement behaviours among Saudi children aged 6-12 years.

| METHODS
This online cross-sectional survey aimed to recruit children from all 13 regions of Saudi Arabia. The survey was promoted to parents through the Saudi Ministry of Education and on social media.

| Data collection
Eligible parents who resided in Saudi Arabia with a child aged between 6 and 12 years completed the survey between 1 October to 11 November 2020. The survey comprised (a) parental and child demographics, (b) child's movement behaviours, and (c) changes in the child's movement behaviours due to COVID-19. Questions used in the current analyses are shown in Table 1. An online parent information sheet and consent form were completed before commencing the survey. Parents with more than one child were asked to complete a separate questionnaire for each child.

| Survey
The survey was based on a parental survey of young children's movement behaviours during COVID-19   Child and parent birth, sex, region of residence, parental education, and income were assessed using standard questions. PA duration was assessed through parents' responses to questions related to their children's time spent playing outside, doing activities to strengthen their muscles and bones, and being physically active for a total of ≥60 min per day in the past 7 days. SB was assessed through questions related to child's time spent watching TV, using a smart phone, using social media, or playing video games (VG) for entertainment for <2 h while sitting or lying down, over the past 7 days. Sleep duration was assessed through questions related to children's wake up and sleep times, while sleep quality was assessed based on a scale of 1 to 7. Parents reported the balance of their child's overall healthy movement behaviours compared with before COVID-19 using a 5-point

Key Messages
• This research examined the impact of COVID-19 on 24-h movement behaviours among Saudi children during the COVID-19 pandemic.
• Children's PA levels declined, they slept more, and their use of electronic screen devices significantly increased.
• The perceived changes in PA and SB were more unfavourable among girls than boys.
• The Ministry of Education, parents, and children need to work together to address the adverse impact of COVID-19 on Saudi children's movement behaviours.
Likert scale ranging from a lot worse (score = 1) to a lot better (score = 5).

| Statistical analyses
Data were downloaded from Qualtrics and manually checked and cleaned in Excel. Statistical analyses were carried out using SPSS software (version 27, Chicago, IL, USA). Sample characteristics were summarized using the mean and standard deviation and percentage of children meeting 24-h movement guidelines. Pearson correlations were used to test associations between parent age and the time their child spent in PA, SB, using social media, and sleep. Differences between boys and girls in the time parents reported their child spent in PA, SB, using social media and sleep were assessed using independent samples t-tests. Spearman's rank order correlations were used to assess associations between parent education level and income and time their child spent in PA, SB, using social media, and sleep. A 95% confidence interval for the percentages were calculated by using the formula of proportion: A forest plot was used to present parent-reported changes in 24-h movement behaviours of the children. Statistical significance was set at p < 0.05 for all analyses.

| Parent and child characteristics
A total of 1021 parents completed the survey, of which 78.8% were Saudis. There were 2799 parents who started, but did not complete, the questionnaire. Parents were required to complete all questions before they could submit the survey. Fifty-five per cent of respondents were mothers with an average age of 41 (±9.2) years. The mean age of the children was 8.5 (±1.85) years. Sixty per cent of the study sample were girls. Parents' average monthly income was $4355. Onequarter of parents had a high school, 41% had a bachelor's degree, and 14% had a master's or PhD. Compared with the Saudi population, our sample of parents comprised more mothers and was slightly older.
The monthly income and education levels were similar to the Saudi population (General Authority for Statistics, 2017Statistics, , 2018Statistics, , 2021 ( Table 2).
T A B L E 1 Selected items used in the current analysis from the child survey during COVID-19 virus outbreak

Current movement behaviours
• Over the past 7 days, on how many days was your child physically active for a total of at least 60 min per day? • During the past 7 days, on how many days did your child do activities to strengthen their muscles and bones? • Over the past 7 days, on how many days did your child watch TV/videos/internet using a smart phone or tablet or play video or computer games for entertainment for less than 2 h while sitting or lying down? • During the past 7 days, on average how much time per day did your child play outside? • How many hours of sleep does your child get in a typical 24-h/day (including naps)? • On a scale of 1 to 7, with the higher number indicating higher quality, how would you rate the quality of your child's sleep?

Change in movement behaviours
Compared with before the COVID-19 outbreak and related restrictions: • My child is doing physical activities or sport outside? • My child is doing physical activities or sport inside? •   The results of the Spearman correlations (Table 5)  Parent income level (Table 5) showed a significant negative correlation with the time their child spent in outside PA/sport (r = À0.06, p = 0.04) and the quality of their child's sleep (r = À0.06, p = 0.049), and a significant, weak negative correlation in their child's overall healthy movement behaviours (r = À0.10, p < 0.0001). In addition, T A B L E 3 Children's movement behaviours during the COVID-19 virus outbreak and compared with before COVID

| New ways families are approaching movement behaviours
Almost half the parents (42%) indicated that their child was involved in more inside leisure activities during COVID-19 than before COVID-19. These included drawing (32.8%), playing VG (14.9%), playing soccer (13%), playing Intelligence Quotient games (11.1%), reading stories (6.1%). and yoga (4%). Few children were involved in sewing/crafts, house framing, and dancing (3%). Only 17% of parents indicated their child was involved in more outside leisure activity during the COVID-19 outbreak. These included running (23.6%), hiking (17.2%), swimming (14.4%), visiting relatives (11.5%), martial arts (9.8%), photography (9.2%), biking (8.6%), and gymnastics (5.7%).  (Kovacs et al., 2021;Moore et al., 2020;Xiang et al., 2020). We found marked increases in time children spent in SB. It is likely these changes are a result of the government restrictions put in place due to COVID-19, which limited children's opportunities to play outdoors (Kovacs et al., 2021). Moreover, as parents were working from home, they likely allowed their children to use electronic devices for longer periods of time to keep them busy as they worked . This finding may explain the significant increase in SB and the decrease in PA levels. School closures may be another reason for the decrease in children's PA levels. These may include not walking to school, which is associated with a decrease in PA levels (Faulkner et al., 2013).

| DISCUSSION
Most children in the study did not have consistent bedtimes or wake-up times during COVID-19. As our data showed, on average children had later bedtimes (after 11 pm) than before COVID-19. This may be explained by their increased use of screen devices in the 2 h before bedtime. However, the starting time for school was much later (15:30) during COVID when schooling was remotely delivered. This much later starting time likely explains the increase in sleep duration.
Moreover, 40% of children had a screen device in their bedroom, and this practice has been shown to be associated with lower sleep duration and quality (Chaput et al., 2014). Further, parents may be inadvertently influencing the quality of their child's sleep by using electronic devices during bedtime routines with their children  Note: Parents education = primary school, high school, diploma, bachelor's degree, master's degree and PhD. Monthly income = 0-3000, 3000-7000, 7000-10,000, 10,000-15,000, 15,000-20,000, more than 20,000. *Correlation is significant at the 0.05 level (2-tailed).
long-term health consequences including hypertension, dyslipidaemia, weight gain, and metabolic syndrome (Medic et al., 2017). As children are influenced by the feelings and behaviours of their parents through observation and imitation (Bandura, 2008), modelling and encouraging these behaviours may help children meet the sleep and SB recommendations.
Internationally, a large proportion of children are not meeting the 24-h movement guidelines (Roman-Viñas et al., 2016). However, the percentage of Saudi children not meeting 24-h movement behaviour guidelines was much lower than international studies conducted before the COVID-19 pandemic. A multinational survey of schoolaged children to evaluate adherence to integrated movement behaviours in 12 countries showed that around 7% of children met the three recommendations (Roman-Viñas et al., 2016).
The current study found that girls were less active than boys during the COVID-19 pandemic. The decrease in PA levels can be partially explained by gender differences. For example, it has been reported that boys are more active than girls and that the gender difference in total amounts of activity is mainly due to gender differences in the amounts of self-organized PA (Nielsen et al., 2011).
However, it could also be due to lower levels of PE among girls in  (Kovacs et al., 2021;Tu et al., 2017). Parents should be encouraged to be more active with their children as they are a role model for their children (Brouwer et al., 2018).
To our knowledge, this is the first study in Saudi Arabia that investigated the cross-sectional impact of COVID-19 on movement behaviours among Saudi children (aged 6-12 years). A limitation of the study is that movement behaviours were subjectively captured via an online parent questionnaire; however, it was not possible to collect data using device-based measures on a large sample due to the COVID-19 pandemic. Using 24-h movement guidelines from other countries is another potential limitation, highlighting the need to develop country-specific guidelines for Saudi Arabia. Further, just over 70% of parents who started the questionnaire did not complete it, and it is not known if these parents differed from those who did complete the questionnaire.

| CONCLUSIONS
The results of the current study demonstrate the impact of the Librarians.

CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.